WMA CERTIFIED MEMBER MEDIATOR APPLICATION
Name:_____________________________________________
New WMA Member? Y/N
Address:___________________________________________
City:_______________________________ State: _________ Zip: __________
Phone: _________________________(W) _________________________(Cell)
E-mail:___________________________________________________________
You may submit most of the required materials by email to [email protected]. If you choose this
option, you must also mail the original Affidavit of Compliance to the address in the next paragraph.
If you choose to submit your full application by mail, send one set of all the required materials to:
WMA, 1122 E. Pike Street, PMB #1095, Seattle, WA 98122-3934.
Affidavit must be original; photocopies are acceptable for all supporting documentation. It is suggested that you keep a
full copy of your application for your records.
Your application should include, in this order: (There is no need to include the Appendices of the application.)
1) THIS FRONT PAGE – Must be completed. If you would like to complete this portion on your computer, we suggest you
cut & paste this front page into a word-processing document.
2) COVER LETTER – Must be signed and include:
 Whether you are applying as an Experienced Practitioner, under the Practicum Completion option, or are an Out of
State applicant (See Appendix II of the WMA Application)
 If you have had any felony convictions or have been a respondent in any professional liability claims, please
include an explanation in your letter
3) FEES DUE (Make checks payable to WMA)
 Certification Application Fee
 Membership Fee, if you are a new member or your membership is due for renewal
$100
$ 75
4) MEMBERSHIP APPLICATION, only if you are a new member
5) AFFIDAVIT OF COMPLIANCE
 Original, signed and notarized
 Original must be mailed to WMA (see address above), even if you are submitting by email
6) DOCUMENTATION SECTION I: BASIC MEDIATION TRAINING See Appendix 1 of the WMA Application.
7) DOCUMENTATION SECTION II: MEDIATION EXPERIENCE
 See Appendix II of the WMA Application.
 Support documentation may be in the form of the WMA Generic Certification Mediation Log.xls or the format of
your choice, as long as it contains the same information (mediation dates, type, duration, and totals) in a clearly
readable form.
 Remember to include a letter of recommendation when required.
8) DOCUMENTATION SECTION IV: ANY ADDITIONAL DOCUMENTATION
 This may include additional, optional supporting documentation such as a resume, letters of support, etc.
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WMA CERTIFIED MEMBER MEDIATOR APPLICATION
Rev. 1/28/15
WASHINGTON MEDIATION ASSOCIATION
AFFIDAVIT OF COMPLIANCE
STATE OF ________________________________ COUNTY OF______________________________
I, ___________________________________being first duly sworn, depose and say that: I am the applicant
named who has signed this application for approval of Certified Member Mediator in the Washington
Mediation Association.
By signing this affidavit, I attest that I have fulfilled the requirements set out in the application upon which I
have submitted my name, and agree to continue to abide by WMA’s Standards of Practice and Grievance
Procedure.
I also attest that, unless explained in attached documentation, I have not been a respondent in a professional
liability claim and I have never been convicted of a felony.
I understand that the determination as to whether I qualify under the above categories, as well as my
continuing membership, depends upon the truth, falsity, or completeness of my answers set forth in this
application and any attached statements.
To my knowledge, the answers and information which I have supplied in connection with this application are
true and complete.
Applicant’s Signature ________________________________ Date: _________________
Subscribed and sworn to before me this_________day of__________, ______.
(Seal)
___________________________________________ NOTARY
PUBLIC FOR ______________________ RESIDING AT
______________________________
MY COMMISSION EXPIRES __________________
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WMA CERTIFIED MEMBER MEDIATOR APPLICATION
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Appendix I
Basic Mediation Training
Applicants must successfully complete a Basic Mediation Training (BMT) that includes at least 36 hours of
actual training experience. The BMT curriculum should include the following components:
1. ADR AND MEDIATION: An explanation of mediation in the continuum of dispute resolution alternatives that
include discussions of different styles of mediation and how to assess the appropriate style for individual cases.
2. THEORY: Explanation of negotiation and conflict theory, including an analysis of conflict styles, distributive
and integrative bargaining, BATNA, and types of joint gains.
3. SKILLS: Training that includes, but is not limited to, communication and listening skills, identifying
underlying interests and motivations, assessing the impact of cultural differences on negotiation.
4. INTAKE AND ASSESSMENT: Training on intake and assessment procedures should include screening parties to
determine if the dispute is appropriate for mediation.
5. MEDIATION PROCESS: Training in and application of components of the mediation process including:
mediator’s opening statement, the parties’ opening statements, agenda setting, negotiation, generating and
evaluating options, caucus, agreement writing and closure.
6. ETHICS: Discussion and analysis of ethical issues in mediation, standards of practice, and Washington State
statutes pertaining to mediation.
7. EXPERIENTIAL LEARNING: Twelve hours of interactive exercises including supervised mediation role-play.
BASIC MEDIATION TRAINING DOCUMENTATION
The following documentation needs to accompany the application:
1. Certificates of completion issued by the individual or organization that conducted the training, or if offered
through a college or university, verification of attendance or completion. (Note: Graduates of any 40 hour
Academy of Family Mediator or WMA approved Washington State Dispute Resolution Center basic mediation
training need only submit certificate of training to meet this requirement. Documentation for items 2 & 3 below
are not required.)
2. Number of training hours completed – provide a list of courses with associated hours, and total the number of
hours taken; and
3. Identification of how all components listed above has been acquired. Course outlines, syllabus, or similar
documentation is required.
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WMA CERTIFIED MEMBER MEDIATOR APPLICATION
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Appendix II
Mediation Experience
Applicants can meet the experience requirement through any one of the following three options. It is not
necessary to satisfy both the requirements of Option A and of Option B.
OPTION A: EXPERIENCED PRACTITIONERS
A WMA member can satisfy Option A if the member has at least 200 hours of mediation experience in the last
10 years and submits a letter of recommendation.
The following documentation must accompany the application and must include:
1. The approximate total number of hours of mediation experience and the time period;
2. A listing of the types of cases mediated and number of hours per type;
3. Mediation Log which includes: date of mediation, location, type of case, duration of mediation,
supervised hours and total hours. (Reference: WMA Generic Certification Mediation Log.xls for a
sample document.);
4. The name(s) of the organization(s) for which the mediations were conducted;
5. A letter of recommendation from an experienced mediator or mediation organization referencing the
applicant’s specific mediation abilities. It should include how the applicant manages the mediation
process and how s/he relates to the parties. The recommendation can be based on personal co-mediation
experience with the applicant, client evaluations, or a review of other co-mediator evaluations.
OR
OPTION B: PRACTICUM COMPLETION:
A WMA member can satisfy Option B if the member has
1. At least 24 hours of supervised mediation at either a Washington State Dispute Resolution Center
WMA pre-approved practicum
or
A WMA pre-approved practicum that meets all the qualifications required in the current manual for
approved DRC Practicum providers. (Note: Please check with your DRC or our WMA website:
www.WashingtonMediation.org, Mediator Certification tab, Practicum Information page for a list of
WMA approved Practicum Programs.)
And
2.
A minimum of 36 additional hours of post-practicum mediation.
The following documentation must accompany the application and must include:
1. A certificate and/or statement of completion from the DRC or the WMA pre-approved practicum
indicating the applicant’s successful completion of their Practicum under the direction of a WMA
qualified practicum supervisor;
2.
A listing of the types of cases mediated and the number of hours each type represents for both the
24 hours of supervised mediations and the minimum 36 hours of post-practicum mediation
experience;
3.
Mediation Log which includes: date of mediation, location, type of case, duration of mediation,
supervised hours and total hours. (Reference: WMA Generic Certification Mediation Log.xls for a
sample document.)
OR
OPTION C: OUT-OF-STATE APPLICANTS: A WMA member who has gained mediation experience in
another state will be considered on a case-by-case basis. Required documentation of mediation experience will
be similar to that in Option A (or Option B only if practicum is pre-approved).
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WMA CERTIFIED MEMBER MEDIATOR APPLICATION
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